NCG050172_DMR_20220128

STORMWATER DISCHARGE OUTFALL(SDO)
/�C�Cr MONITORING REPORT
Permit Number NM 0500 0 �l Dl ,NO �v���2 SAMPLES COLLECTED DURING CALENDAR YEAR: 14`
(This monitoring report shall be received by the Division no later than 30 days from
T 1 the date the facility receives the sampling results from the laboratory.)
FACILITY NAME N G I'S� �06 �'t'r�' ' �'� COUNTYPr
PERSON COLLECTING SAMPLE(S) PHONE NO. 12) 7 1(0 1
CERTIFIEDLABORATORY(S) Al AR Lab#
Lab#
SIGNATURE OF PERMITTEE OR DESIGNEE
REOUIRED ON PAGE 2.
Part A: Specific Monitoring Requirements
Outfall Date 50050
No. Sample Total Total
Collected Flow if a Rainfall
mo/dd/ r MG inches
B
FILE
ON
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?Dyes ono
(if yes,complete Part B)
Part B:Vehicle Maintenance Activity Monitoring Requirements
Outfall Date 50050 00556 00530 00400
No. Sample Total Flow Total Oil&Grease Non-polar Total pH New Motor
Collected (if applicable) Rainfall (if appl.) O&G/TPH Suspended Oil Usage
(Method 1664 Solids
SGT-HEM),if
a I.
mo/dd/ r MG inches in /I m I unit al/mo
Form S W U-247,lust revised 611212015
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STORM EVENT CHARACTERISTICS: Mail Original and one copy to:
Division of Energy Mineral and Land Resources
Date Attn:Central Files
Total Event Precipitation(inches): 1617 Mail Service Center
Event Duration(hours): (only if applicable—see permit.) Raleigh,North Carolina 27699-1617
(if more than one storm event was sampled)
Date
Total Event Precipitation(inches):
Event Duration(hours): (only if applicable—see permit.)
"I certify,under penalty of law,that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person
or persons who manage the system,or those persons directly responsible for gathering the information,the information submitted is,to the
best of my knowledge and belief,true,accurate,and complete. I am aware that there are significant penalties for submitting false information,
including he possib i of fines and imprisonment for knowing violations."
o► 2� WV
Si at Per ittee (Date)
Form SWU-247,last revised 611212015
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